ASSESSMENT PADIS Flashcards
GENERAL APPROACH TO ASSESSING
THE TOXICOLOGY PATIENT
n Airway
n Breathing
n Circulation
n Decontamination
n Elimination
n Find an antidote
n General management
n History and physical
The Toxic Emergency
Components of Assessment
STABILIZATION (ABC’S)
HISTORY PHYSICAL EXAMINATION DIAGNOSTIC TESTS
see slide 4
STABILIZATION
n Never forget the ABC’s
n The cause of the symptoms doesn’t change
the approach to stabilizing the patient
n Assess adequacy of airway and ventilation
n Assess cardiovascular system
n Assess mental status or level of
consciousness (GCS)
The cause of poisoning is SECONDARY to stabilization
ABC’S
n Airway
n Foreign body?
n What color is the patient?
n Breathing
n Can you hear choking, gagging, stridor or wheezing?
n What about speech - full sentences, slurred speech?
n Circulation
n Lethargy? dizzy? skin color?
n If patient described as “passed out”, “dopey”, “spaced
out”, or “out of it” what does that mean?
HISTORY
n After stabilization complete
n Goals:
n To obtain further information about patient and
the situation
n To determine if exposure is toxic vs non toxic
n To obtain the information needed to make your
final assessment and plan for care
HISTORY- Toxic vs Nontoxic
n General concepts:
n Is the history consistent with the presenting
symptoms? (Does the poison match the patient
presentation?)
n Keep a high index of suspicion if symptoms don’t
“fit”
n Consider an alternate toxin or differential
diagnosis (medical condition)
HISTORY – Common Problems
n History often unreliable or absent (eg
patient found unconscious)
n Patient may not know, or may not be able to
verbalize what they ingested
n Patients may not want to volunteer what
they ingested
n Ask family, friends, paramedics or bystanders if
any additional history available
HISTORY – Things to Consider
n Was this a witnessed exposure?
n Family, paramedics, bystanders, friends
n Ask them to go over history with you
n Where the patient was, what they were doing, and what
happened
n Past medical/psychiatric history
n Medications (Use Netcare where appropriate to
know “what cards are in the deck”)
n History of illicit drug use
n Circumstances
n Work/hobbies
n Preceding symptoms
n Any one else ill?
n Pregnancy
HISTORY - Paramedic
n Paramedics at the scene often gather up all
the bottles in the area
n May need to sort out which they’ve actually taken
n Paramedics may be only people to speak
with first hand witnesses
n May be helpful to get them to go over what
THEY saw on scene
n Who called EMS?
What did this person take?
The 10 Ps of Poison History taking
n 1) Check Pockets
n 2) Ask the Patient
(Duh!)
n 3) Ask
Parents/Partners/Pals
n 4) Prehospital
personnel (EMS)
n 5) PADIS
n 6) Pedestrians
(Probably Low yield)
n 7) Police
n 8) Personal MD
n 9) Past History (old
chart)
n 10) Pharmacy
Physical Exam
n Head to toe approach
n Mental status,
behaviour
n Vital signs including
temperature
n Respiration quality
n Skin
n Pupils
n Bowel sounds
n Muscle tone
n Reflexes
n Odors - less frequent
n Secretions
LOC, behaviours
Vital signs most often necessary to diagnose a toxidrome
Pupils give high yield
Same with skin
ASSESSMENT - ORAL/PARENTERAL EXPSOURE
n Review systems
n CNS
n CVS
n Respiratory
n GI/GU
n Don’t forget
n Pupils
n Odors
n Temp
n Muscle Activity
n Skin appearance/feel
ASSESSMENT - DERMAL
EXPOSURE
n What does the skin look like?
n Red, irritated, blistered, swollen, blue or grey?
n What does patient describe skin as feeling like?
n Painful or Itchy?
n Has skin been irrigated? What was the result?
n What other treatments has patient already
done?
n Have they put any creams/ointment on?
n Did they attempt to “neutralize” agent?
ASSESSMENT - EYE EXPOSURE
n Can the patient open the eye?
n Is it red or swollen?
n Tearing or other purulent drainage
n pH, eye exam
n Foreign body sensation
n Visual acuity
n Photophobia
n Has eye been irrigated? What was the result?
ASSESSMENT - INHALATIONAL
EXPOSURE
n ABC’s important here
n Has the patient had fresh air?
n Coughing/choking
n Audible wheezing or stridor
n Able to speak full sentences?
n Was patient wearing any protective equipment?
e.g. respirator
n What about rescuers? Were they exposed? e.g.
H2S?
GLASCOW COMA SCALE
eye opening
motor response
verbal response
Out of 15
Lowest score is 3
Highest is 15
Intubated pt scored out of 10
Not validated in context of poisonings
As GCS goes down, less likely to protect airway
Less than 8 intubate for head injury - can use as ref for poisoning
LABORATORY and DIAGNOSTICS
Don’t just order a test without a rationale for
that test
n Example: If the poison in question doesn’t impact
blood count, don’t recommend a CBC.
n You need to be prepared to do something
about the results of that test. (Own IT!)
n Consider the impact on:
n Health Care System AND Patient
n Can be used to identify or confirm toxin
n Assess degree of toxicity and patient’s need for
treatment
n Common chemistry tests which PADIS
frequently considers:
n Electrolytes, BUN, glucose, ABGs, anion gap, osmol gap
CO2 or bicarb - does pt have anion gap?
n ECG, chest X-ray, abdominal X-ray
n Drug levels, Tox screens
Toxic alcohols - osmol gap
Arterial blood gas or venous blood gas (less painful)
Wide QRS or QTc is important
Body packer amy be seen in X- ray
“Drug Screens”
n Typically 2 types
n Immunoassay screening test
n Quick, many limitations, risk of false positives
n UDS: The Urine Drug Screen (AKA the Useless
Drug Screen)
n Rarely change management. (So why do it?)
n Comprehensive Intensive (Call Tox Lab)
n Usually done with LC/MS or GC/MS
n Can takes days to weeks
Urine drug screen: “Pee on a stick”
n Does not replace clinical judgment
n They are a single piece of information to consider
in the clinical picture
n Rarely make a clinical difference
n Differs from lab to lab
n Not all toxins screened
n Cross-sensitivity can be an issue
A drug screen cannot rule in poisoning.
At best, it can support a diagnosis
Comprehensive Urine Drug Screens
(Using LC/MS)
n Labour intensive
n Lengthy to perform
n Used most often for academic or medicallegal purposes
n Rarely contribute to management of the
poisoned patient in the acute situation
When to get a fancy Comprehensive
LC/MS test?
Suspicion of child abuse, homicide, sexual
assault
n Some patients with brain death (rule out
toxicologic cause for clinical picture)
n New Public Health Outbreak (Carfentanyl/
PMMA)
n Delirium/altered mental status
unexplained by other cause
DRUG LEVELS
n Quantitative measurements
n Few substances where clinically relevant
n Limited by availability at each hospital
n Different labs have different capabilities
n If they CAN do level, it may have a different
sensitivity level than other labs
Examples of Toxins with Clinically
Relevant Quantitative Levels
n Acetaminophen
n Salicylate
n Iron
n Digoxin
n Lithium
n Anticonvulsants
n Methanol
n Ethylene glycol
n Isopropyl alcohol
n Heavy metals
n Carbon monoxide
